Very specific thoracic epidural question

[caligas]

I have been doing more and more thoracic epidurals due to local changes in surgeon preference. I have a very specific technique question.

I use a paramedian approach. As soon as i walk of the lamina go to l.o.r. syringe. Occasionaly when i put the syringe on, there is no real resistance. So the question: do you just advance the needle until you have good resistance OR try to thread the catheter OR start over with a different angle OR something entirely different?

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[nimbus]

I thread the catheter. If it advances easily, you're good to go. If not, start over.

 

[caligas]

But if cath doesnt thread ez, you would not advance needle without resistance, correct?

 

[nimbus]

But if cath doesnt thread ez, you would not advance needle without resistance, correct?

It depends. If I'm still shallow and I get the sense that I never engaged the ligamentum flavum, I might advance.

As an aside, I've had a couple of wet taps doing tepi and they have not developed headaches. Just an anecdote.

 

[caligas]

Cool, thanks.

I think my fear is hitting the cord more than the headache. But definitely getting more comfortable.

 

[Peezy23]

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[caligas]

I would first plae a small amt of saline through the needle and attempt to check resistance. If saline goes in like butter then try to thread catheter. If it doesn't also go like butter you ar not in. Flick the needle and see if it bounces around (like a needle in fat) or if it is firm. If it just moves wherever itwants your are too shallow or past point. Check your landmarks and advance slowly. Also you can always use your 25G local needle as a finder. Attempt to locate the lamina again. You may be to lateral and actually on TP or too medial and on SP. The feel of the Ligament is very distinct. You just have to get more comfortable with going deeper and knowing you are not going to stab the cord. I would also suggest trying midline approach for TE placement. Most people have a nice midline space and it is actually easier unless they are very small with tiny spaces, elderly with arthritic spaces or obese with poor landmarks. I place all of my TE's midline in abt 6 minutes unless the patient meets any of the above criteria, then I go paramedian

Yes, my "bailout" has been to go midline around T10/11 and thread the catheter up and use dilaudid to help with spread.

 

[deleted162650]

I do mine paramedian as well. In the situation you described I would come back to lamina and walk off again. I don't hook up the LOR syringe until I feel the needle tip imbed in the ligament with that nice "corky" feel. The ligamnetum flavum is thicker than you think (or at least than I thought). I know what you're talking about with that immediate LOR off the lamina, and I think there is defiitely a plane superficial to the ligament that can provide a "false loss" but is certainly not epidural space.

On a side note, I switched to doing mine with the pt in the lateral position. You can sedate them more without having to worry about them moving around/wiggling on you and making your life difficult.

 

[Arch Guillotti]

I thread the catheter. If it advances easily, you're good to go. If not, start over.

Disagree. I have done that before and the epidural didn't work.

I would reorient yourself and make another pass.

 

[nimbus]

Disagree. I have done that before and the epidural didn't work.

I would reorient yourself and make another pass.

I should have specified it only works with the supersoft catheters which is what I use. The stiff ones can be advanced into the wrong plane.

 

[bcat85]

I typically use a hanging drop technique starting from when I step off of the lamina. I find it tends to make the needle easier to manipulate and it makes it easier to feel engagement in the ligament. Once I see a change in the drop, I confirm with the syringe and pass the catheter.

 

[ranvier]

I still start midline. With positioning, I find the thoracic spinous processes do open despite a caudad angulation. Then with good ligamentous engagement, I use a continuous technique just like lumbar labor epidurals. Paramedian is my plan b. I don't do continuous pressure on kids (asleep) but now that I'm out, I don't do asleep blocks. As a resident, doing blocks in pain clinic with fluoro helped me bridge the image with tactile feedback.

My academic attendings pushed the paramedian for thoracic. One did hanging drop.

 

[Uegis]

You can always try to hang a saline column on extension IV tubing with a three way stop. If the saline column drops and shows variation with respiration, chances are good it is in the epidural space. The column will not drop or at least not drop smoothly in a false passage without pressure ie with a LOR saline and your thumb finger pushing against it. Not foolproof but at least gives you an idea. During residency, we did all of our thoracic epidurals with saline column confirmation and almost exclusively did paramedian approach.

 

[Planktonmd]

You can always try to hang a saline column on extension IV tubing with a three way stop. If the saline column drops and shows variation with respiration, chances are good it is in the epidural space. saline column confirmation and almost exclusively did paramedian approach.

Or the pleural space or the para-vertebral space....

 

[Mman]

I go paramedian and use LOR saline. Used to do hanging drop by whenever it was iffy I'd check LOR, and figured why waste the time of even bothering with the drop? Anyways I bang into lamina and then redirect medially to the same depth as the lamina. At that point I either hit the spinous process and have to redirect up or down or I'm in ligament and I check LOR. I never get LOR at that depth. If I did, I'd go back to lamina and reassess because something ain't right.

 

[Gas you down]

I'm with Nimbus. I use the CSE kits and the cath is damn near impossible to put somewhere other than the epidural space. I guess if you're still unsure you could use the spinal needle included to confirm. if you see csf, you've got to be in the right ballpark.
the squishy cath is key. those other catheters are too stiff and can mislead you

 

[RxBoy]

Anyways I bang into lamina and then redirect medially to the same depth as the lamina. At that point I either hit the spinous process and have to redirect up or down or I'm in ligament and I check LOR. I never get LOR at that depth. If I did, I'd go back to lamina and reassess because something ain't right.

Was gonna mention this... This is my exact approach with spinals because there is a confirmed end point, CSF or no CSF. However with epidurals I find the lamina then walk off of it medially until I find the spinous process. Basically, I always try to find the spinous process. If I dont find the spinous process, I pull back the needle to skin and move the skin up or down then reapproach.

My landmark is to hit the spinous process and bury my needle in the corner between the process and lamina. From there go cephalad or caudal until you stop feeling bone, then attach the LOR syringe. I do this because in the middle/upper thoracic space I find there is a high risk of getting a false LOR unless you can truly orient yourself to the anatomy.

Nothing is worse than doing all the work to get an epidural and then failing miserably because a false LOR.

 

[RxBoy]

As for the residents, try different approaches before you stick to just one. You'll eventually find the approach thats most comfortable.

 

[okayplayer]

I'm with Nimbus. I use the CSE kits and the cath is damn near impossible to put somewhere other than the epidural space. I guess if you're still unsure you could use the spinal needle included to confirm. if you see csf, you've got to be in the right place

I probably would not do that.

 

[HalO'Thane]

Another observation that I have made is that the ligamentum flavum in the thoracic region is much thinner than that of the lumbar region, so LOR is much more subtle. For this reason I would also try to thread the catheter. With our epidural kits I also feel that it is difficult to thread the catheter unless it is in the epidural space (or spinal canal, which hopefully you will have differentiated)

 

[Urzuz]

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933866

I follow the method prescribed by the authors of this article. Ever since I started doing my thoracic epidurals this way, I have never had one fail. I strongly recommend reading it and trying their method. They have great pictures that really help you visualize the three dimensional anatomy of the thoracic spine while placing epidurals. Also, studying the spine of a skeleton model helped tremendously.

 

[Mman]

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933866

I follow the method prescribed by the authors of this article. Ever since I started doing my thoracic epidurals this way, I have never had one fail. I strongly recommend reading it and trying their method. They have great pictures that really help you visualize the three dimensional anatomy of the thoracic spine while placing epidurals. Also, studying the spine of a skeleton model helped tremendously.

that's pretty much what I do except in more words. I think it's a solid technique. I hesitate to say one can't fail, though, despite the best technique. Not every patient's spine looks like the textbook.

 

[psychbender]

I use the same midline technique for thoracic as I do lumbar epidurals. I experimented with paramedian in residency, but it just never felt right (probably because I didn't start trying it until late), and my success rate with midline was quite high, even for thoracotomies and mastectomies.

 

[Urzuz]

that's pretty much what I do except in more words. I think it's a solid technique. I hesitate to say one can't fail, though, despite the best technique. Not every patient's spine looks like the textbook.

100% agree. I've just been lucky with my patients' anatomy 🙂